UHS Medical Scribe Training: Clinical Documentation, Anatomy, and Diagnostics

Comprehensive vocabulary flashcards covering clinical documentation, diagnostic orders, common laboratory evaluations, imaging modalities, anatomical terminology, physical examination maneuvers, obstetrics and gynecology, dermatology, psychopharmacology, and gender-affirming care from the UHS Scribe Course.

Assessment

The clinical documentation section in a SOAP note describing the patient's addressed problem, relevant past medical history (PMHx), potential differential diagnoses, and relevant new diagnostic test results directly related to the condition.

Plan

The clinical documentation section in a SOAP note specifying the care steps for the patient, including diagnostic orders (labs and imaging), prescriptions, patient counseling or lifestyle recommendations, and follow-up timing.

Routing

An informal internal communication method within an electronic health record (EHR) used to transfer a patient's chart to specific members of the healthcare team, such as sending records to an eligibility specialist for insurance coverage verification.

Precharting

The preparatory workflow completed prior to a clinical visit that involves setting up visit-specific documentation templates, reviewing and summarizing prior assessment plans or hospitalizations, and identifying outstanding healthcare maintenance items.

Prothrombin Time / International Normalized Ratio (PT/INR)

A coagulation study ordered to monitor the therapeutic effect of the oral anticoagulant Coumadin (warfarin) in patients at risk for thromboembolic stroke.

Basic Metabolic Panel (BMP)

A routine blood test evaluating fluid status, kidney function, and electrolyte levels, measuring blood urea nitrogen (BUN), calcium, carbon dioxide, chloride, creatinine/eGFR, glucose, potassium, and sodium.

Comprehensive Metabolic Panel (CMP)

A diagnostic blood panel that contains all eight parameters of the basic metabolic panel (BMP) combined with a comprehensive biochemical evaluation of liver function.

Complete Blood Count with Differential (CBC w/ diff)

A routine hematology laboratory test measuring red blood cells, hematocrit, hemoglobin, and platelets, alongside a detailed white blood cell breakdown (including neutrophils and monocytes) to identify anemia, leukemia, or acute and chronic infections.

Creatine Kinase (CK)

A serum enzyme biomarker ordered to detect severe skeletal muscle breakdown and tissue injury indicative of rhabdomyolysis.

Brain Natriuretic Peptide (BNP)

A cardiac neurohormone biomarker measured in serum to screen for and evaluate the presence and severity of congestive heart failure.

Hemoglobin A1c (Hgb A1c)

A glycated hemoglobin laboratory assay used to diagnose prediabetes and diabetes mellitus by quantifying average blood glucose control over a $3$-month window.

Computed Tomography (CT) Scan

A cross-sectional diagnostic imaging modality that rotates around the patient to obtain multiple radiographic slices, which computer algorithms assemble into detailed $3\text{D}$ images of organs, soft tissues, and bone structures.

Magnetic Resonance Imaging (MRI)

A non-ionizing diagnostic imaging modality utilizing powerful magnetic fields and radiofrequency pulses to generate detailed soft tissue images of the brain, spinal cord, musculature, tendons, and vascular structures.

Ultrasound

A radiation-free, real-time diagnostic imaging modality that utilizes high-frequency acoustic waves emitted and received via an acoustic transducer and acoustic gel to image soft tissues, monitor fetal development, and guide procedural needles, costing approximately $100\text{ to }500\text{ dollars}$.

Positron Emission Tomography (PET)

A specialized nuclear medicine imaging technique tracking cellular biochemical function, blood flow, and metabolic glucose consumption at a spatial resolution of $4\text{ to }6\,\text{mm}$, widely used in oncology staging, myocardial perfusion assessment, and dementia evaluation.

Anatomical Position

The universal reference posture in which a subject stands completely erect with head facing forward, arms resting at the sides, palms turned anteriorly forward, and thumbs oriented pointing away from the body.

Prone

An anatomical orientation in which the patient lies recumbent with the chest, abdomen, and ventral surface facing downward.

Supine

An anatomical orientation in which the patient rests horizontally on their back with the ventral surface and face directed upward.

Proximal

A directional term indicating a position closer to the trunk or origin point of an appendage.

Distal

A directional term designating a point situated farther away from the trunk or origin point of an appendage.

Superior

A directional term describing an anatomical position located toward the head or upper aspect of the body.

Inferior

A directional term describing an anatomical position oriented toward the feet or caudal aspect of the body.

Medial

An anatomical directional reference designating a structure located closer toward the vertical midline of the body.

Lateral

An anatomical directional reference denoting a structure located away from the body's midline toward the outer perimeter.

Adduction

A joint movement that translates a limb or anatomical structure toward the midline axis of the body.

Abduction

A joint movement that moves a limb or anatomical structure laterally away from the midline axis of the body.

Flexion

A biomechanical movement occurring in the sagittal plane that decreases the angle between two articulating bones or body parts.

Extension

A biomechanical movement occurring in the sagittal plane that increases the angle between two articulating bones or body parts.

Pronation and Supination

Rotational movements of the forearm: pronation rotates the radius over the ulna to turn the palm from anterior to posterior (inward/downward), while supination rotates the forearm to return the palm from posterior to anterior (outward/upward).

Anatomical Planes

The three cardinal geometric reference planes used in anatomy: the transverse plane (dividing into superior and inferior halves), frontal/coronal plane (dividing into anterior and posterior halves), and sagittal plane (dividing into right and left halves).

Vertebral Column Divisions

The structural anatomical organization of the spine, consisting of $7$ cervical vertebrae (including the C1 atlas and C2 axis), $12$ thoracic vertebrae, $5$ lumbar vertebrae, a sacrum ($5$ fused segments), and a coccyx ($4$ fused segments).

Fontanelles

The unossified, fibrous membrane-covered spaces located at the junction of cranial sutures in a newborn skull that permit cranial compliance during birth and typically remain open until approximately $2$ years of age.

Nine Abdominal Regions

The regional grid division of the abdomen consisting of the epigastric, umbilical, and hypogastric regions centrally, flanked bilaterally by the right and left hypochondriac, right and left lumbar, and right and left iliac regions.

Glasgow Coma Scale (GCS)

A standardized clinical assessment score evaluating level of consciousness following head injury or altered mental status based on eye opening ($1\text{ to }4$), best verbal response ($1\text{ to }5$), and best motor response ($1\text{ to }6$), totaling $3$ (unresponsive) to $15$ (fully oriented), with scores $\le 8$ indicating coma.

Muscle Strength Grading

A six-tier manual muscle testing scale from $0$ to $5$, where $0$ is no activation, $1$ is a trace contraction without range of motion, $2$ is full movement without gravity, $3$ is full movement against gravity alone, $4$ is movement against moderate resistance, and $5$ is normal strength against full resistance.

Clonus

A rhythmic, rapid involuntary alternation of muscular contraction and relaxation produced by sudden, passive tendon stretching, commonly elicited by dorsiflexing the ankle.

Romberg Test

A clinical balance test where a patient stands with feet positioned together and eyes closed; a positive finding is denoted when the patient loses balance or falls to one side, indicating a sensory ataxia.

Tandem Gait

A focused neurological walking maneuver requiring the patient to walk in a straight line placing the heel of the leading foot directly touching the toes of the trailing foot to evaluate cerebellar coordination.

Gravida (G)

An obstetric classification reflecting the total number of times a female patient has been pregnant, irrespective of the clinical outcome of each pregnancy.

Para (P)

An obstetric classification quantifying the number of birthing events resulting in viable offspring delivered past $20$ weeks of gestation, where a multifetal pregnancy (such as twins) counts as a single birthing event.

TPAL System

A four-parameter obstetric coding format detailing a patient's parity: T represents Term births ($\ge 37$ weeks), P denotes Preterm births ($20$ to $<37$ weeks), A accounts for Abortuses (induced abortions or spontaneous miscarriages $<20$ weeks), and L counts current Living children.

Nulligravida

An obstetric descriptive term applied to a female patient who has never conceived or experienced a pregnancy.

Primigravida

An obstetric descriptive term applied to a female patient who is pregnant for the first time or has experienced exactly $1$ prior pregnancy.

Crown-Rump Length (CRL)

An ultrasound biometry measurement taken from the vertex of the fetal skull to the bottom of the buttocks between $10$ weeks and $13$ weeks plus $6$ days of gestation used to accurately date a pregnancy.

Estimated Date of Delivery (EDD)

The anticipated date of spontaneous labor onset calculated based on a gestational duration of exactly $40$ weeks ($\text{GA} = 40$).

Premature Rupture of Membranes (PROM)

The spontaneous rupture of the amniotic sac prior to the clinical onset of labor, designated as preterm premature rupture of membranes (PPROM) if occurring before $37$ weeks of gestation.

Episiotomy

A surgical incision made through the perineal tissue during the second stage of labor to widen the vaginal orifice and avoid uncontrolled lacerations.

Bacterial Vaginosis (BV)

An abnormal vaginal dysbiosis clinically presenting with a thin grayish-white vaginal discharge accompanied by a characteristically foul, fishy odor, pruritus, and burning sensations.

Trichomoniasis

A sexually transmitted parasitic infection manifesting with a copious yellowish-green, malodorous vaginal discharge associated with severe genital pruritus, burning, and dyspareunia.

Vaginal Speculum

A dual-bladed medical examination tool inserted and expanded into the vaginal vault to separate the vaginal walls and provide direct illumination and visualization of the cervix and vaginal mucosa.

Pap Smear

A cervical cancer screening cytology test wherein cervical cells are exfoliated using a spatula/brush and evaluated microscopically, recommended every $3$ years for ages $21\text{ to }30$, and every $5$ years with HPV co-testing for ages $30\text{ to }65$.

Copper Intrauterine Device (IUD)

A hormone-free intrauterine birth control device that elutes copper ions into the uterine cavity, serving as the only IUD capable of functioning as emergency contraception when inserted within $5$ days of unprotected intercourse.

McBurney's Point

A localized anatomical point situated two-thirds of the distance along an imaginary line drawn from the umbilicus to the right anterior superior iliac spine (ASIS), where maximal focal tenderness indicates acute appendicitis.

Murphy's Sign

A diagnostic physical exam maneuver where deep palpation beneath the right costal margin elicits sharp tenderness and an abrupt arrest of inspiration, demonstrating acute gallbladder inflammation (cholecystitis).

McMurray's Test

A provocative physical examination maneuver of the knee performed via combined flexion, rotation, and axial loading to evaluate for torn meniscal cartilage.

Lachman's Test

An orthopedic stress examination assessing anterior tibial translation with the knee flexed at $20\text{ to }30$ degrees to evaluate the structural integrity of the anterior cruciate ligament (ACL).

Phalen's Test

A provocative diagnostic test for carpal tunnel syndrome wherein the patient holds maximal active wrist flexion with dorsal surfaces together for $60$ seconds to reproduce paresthesia in the median nerve distribution.

Tinel's Test

A neurological physical examination technique involving light percussion directly over the median nerve at the volar carpal tunnel, eliciting tingling or electric shock sensations in carpal tunnel syndrome.

Otalgia

Ear discomfort or pain commonly originating from cerumen impaction, otitis media, or secondary referred pain from the temporomandibular joint (TMJ), dental abscesses, or pharynx.

Slit Lamp Exam

An ophthalmic diagnostic procedure using a high-intensity slit beam light source combined with a binocular microscope to examine anterior segment ocular structures, including the cornea, conjunctiva, iris, and lens.

Pre-Exposure Prophylaxis (PrEP)

A daily antiretroviral pharmacologic regimen prescribed to HIV-negative individuals at high behavioral risk to prevent viral transmission and maintain negative HIV serostatus.

Post-Exposure Prophylaxis (PEP)

A $28$-day emergency antiretroviral regimen that must be initiated within $72$ hours following potential high-risk exposure to HIV to inhibit viral replication and infection.

Macule

A flat, non-palpable primary cutaneous lesion characterized purely by a circumscribed change in skin color measuring less than $0.5\,\text{cm}$ in diameter (a lesion exceeding $0.5\,\text{cm}$ is termed a patch).

Papule

A solid, palpable, superficial primary skin elevation measuring less than $0.5\,\text{cm}$ in diameter whose aggregation leads to larger plateau-like elevations termed plaques.

Plaque

A plateau-like, solid, elevated primary skin lesion greater than $0.5\,\text{cm}$ in diameter, often formed through the confluence of individual papules.

Vesicle

A small, circumscribed, fluid-filled epidermal blister measuring less than $0.5\,\text{cm}$ (or $<5\,\text{mm}$) in diameter containing serous, lymphatic, or cellular fluid.

Bulla

A large fluid-filled cavity or blister within or below the epidermis measuring greater than $0.5\,\text{cm}$ (or $>5\,\text{mm}$) in diameter, commonly resulting from thermal burns or bullous diseases.

Pustule

A discrete, superficial elevation of the skin containing a visible purulent exudate (pus), commonly observed in acne vulgaris and bacterial folliculitis.

Wheal

A transient, firm, edematous plaque or papule caused by local fluid extravasation into the dermis (urticaria or hive), characterized by evanescent swelling that often resolves within hours.

Erosion

A superficial cutaneous defect involving only partial or total loss of the epidermis without damage to the dermis, which resolves completely without scarring.

Ulcer

A deep cutaneous lesion involving total excavation of the epidermis and penetration into the papillary dermis, characterized by resolution with permanent scar tissue.

Lichenification

A secondary skin change marked by visible cutaneous thickening, leathery hardening, and accentuated skin markings resulting from repeated chronic scratching or mechanical rubbing.

Comedonal Acne

A presentation of mild non-inflammatory acne vulgaris characterized by the clinical presence of open comedones (blackheads) and closed comedones (whiteheads) without prominent scarring.

Isotretinoin

A potent oral systemic vitamin A derivative indicated for treatment-refractory, extensive nodular, or severely scarring acne that acts by suppressing sebaceous gland secretion and regulating epidermal keratinization.

Tinea Pedis

A superficial dermatophyte fungal infection localized to the feet and interdigital spaces (athlete's foot), treated topically with terbinafine or via systemic oral terbinafine tablets.

Onychomycosis

A chronic fungal infection of the nail plate and bed managed topically using ciclopirox medicated lacquer or systemically with oral itraconazole.

Azoles

A class of synthetic antifungal medications, including fluconazole, that inhibit fungal ergosterol biosynthesis and cellular replication.

Corticosteroids

Synthetic steroid hormones administered by mouth, topically, via inhalers, or by injection to suppress immune reactivity and alleviate inflammatory swelling, carrying risks of skin atrophy, hypopigmentation, and heightened susceptibility to infection.

Patient Health Questionnaire-9 (PHQ-9)

A standard $9$-item clinical self-report depression screening tool where scores $\ge 10$ suggest major depression ($5\text{ to }9$ mild, $10\text{ to }14$ moderate, $15\text{ to }19$ moderately severe, and $\ge 20$ severe).

Mania

A distinct psychiatric phase characterized by sustained mood elevation, psychomotor hyperactivity, inflated self-esteem, diminished sleep need, pressured speech, and disinhibition leading to reckless behavior.

Bipolar I Disorder

A severe mood disorder characterized by the emergence of at least one definitive manic episode lasting at least $7$ consecutive days (or requiring acute hospitalization), typically interspersed with major depressive episodes lasting at least $2$ weeks.

Bipolar II Disorder

A mood disorder characterized by alternating patterns of major depressive episodes and hypomanic episodes, lacking the debilitating severity of a full manic episode.

Cyclothymic Disorder

A chronic psychiatric condition marked by recurring subthreshold hypomanic and depressive symptoms that do not meet full diagnostic criteria for hypomanic or major depressive episodes.

Naltrexone

A mu-opioid receptor antagonist serving as a first-line agent for moderate to severe alcohol use disorder ($50\,\text{mg}$ daily orally or $380\,\text{mg}$ IM every $4$ weeks), which can be initiated during active consumption but is strictly contraindicated in patients taking opioids or experiencing acute hepatic failure.

Acamprosate

A first-line oral medication administered at $666\,\text{mg}$ three times daily for maintenance of alcohol abstinence, preferred when naltrexone is contraindicated due to concurrent opioid therapy or acute hepatitis.

Disulfiram

An aversive second-line alcohol use disorder pharmacotherapy ($250\text{ to }500\,\text{mg}$ daily) that blocks aldehyde dehydrogenase, causing an immediate accumulation of toxic acetaldehyde and adverse physical reactions upon ethanol ingestion.

Buprenorphine

A partial opioid agonist prescribed at sublingual doses up to $24\,\text{mg/day}$ to suppress cravings and withdrawal in opioid use disorder with a decreased risk of fatal respiratory depression compared to full agonists.

Gender Dysphoria

The psychological distress and discomfort experienced by an individual due to an incongruence between their internal gender identity and the sex assigned to them at birth.

Gender Affirming Care

A multidisciplinary spectrum of social, psychological, behavioral, and medical interventions endorsed by the World Health Organization designed to validate, support, and align with an individual's gender identity.

Cisgender

A descriptive term indicating an individual whose internal gender identity aligns consistently with their assigned biological sex at birth.

Transgender

A descriptive umbrella term indicating individuals whose gender identity, self-conception, or expression diverges from their biological sex assigned at birth.

Intersex

A clinical term describing an individual born with congenital anatomical, chromosomal, or hormonal variations that do not fit conventional male or female biological classifications.